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Applicant
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Spouse
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| Name: |
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Name: |
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| Current Address:
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City,State,Zip: |
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| Phone |
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E-Mail: |
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| Date of
Birth: |
|
Date of
Birth: |
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Place of
Birth:
(City, State) |
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Place of
Birth:
(City,State) |
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| Age: |
|
Age: |
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| Social
Security Number: |
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Social
Security Number: |
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| Date of
Marriage: |
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Names/Age/Sex of Children in Home: |
|
| Date of Marriage(s): |
|
Date of Marriage(s): |
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| Date of Divorce(s): |
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Date of Divorce(s): |
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References
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Please include names and contact information for at
least 4 non-relatives.
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Name
(Last,First,Middle): |
|
Address
E-Mail: |
|
Relationship
to
Family: |
|
Name
(Last,First,Middle): |
|
Address
E-Mail: |
|
Relationship to
Family: |
|
Name
(Last,First,Middle): |
|
Address
E-Mail: |
|
Relationship to
Family: |
|
Name
(Last,First,Middle):
Relationship to
Family: |
|
Address
E-Mail: |
|
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Adoption, Interest and Preferences
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Please explain briefly your interest and understanding
of Embryo Adoption
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Level of Openness with Donor/s and Donor
Siblings
|
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Please explain your understanding of the
levels of openess and your desired level of openess
|
|
|
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Request names of Reproductive
Endocrinologist Doctor/s in our area.
|
| Need help
with Shipping: |
Yes |
No |
Ship to our
Doctor: |
Yes |
No |
|
| Request names of REPRO
MED DOCS in our area: |
Yes |
No |
|
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Finances
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| |
| Income from
Employment: |
|
Income
from Employment: |
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| Income from other
sources than employment: |
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Sources of other
Income: |
|
| Real Estate Value: |
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Remaining Mortgage
Balance: |
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| Other Total
Indebtedness: |
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Approximate Savings: |
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| Do you have
a current Homestudy? |
Yes |
No |
In Progress |
| If 'Yes'
Date Completed |
|
If 'In Progress'
Completion Date |
| Name of Homestudy
Agency: |
|
Name of Adoption
Assessor: |
|
| Have You ever had a
Homestudy not Approved? |
Yes
If 'Yes' Please explain. |
No |
|
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How Quickly do you want to go in the process?
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(Timely payments of all fees plays a large part in the
time table)
(Check all that Apply)
|
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As Quick as
possible |
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Just getting Started |
|
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Within a
Year would be great |
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Other |
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Additional Information
|
| |
| Have you ever been
convicted of a Felony? |
Yes
If 'Yes' Please explain |
No |
|
| Have you ever been
convicted of a Misdemeanor? |
Yes
If 'Yes' Please explain |
No |
|
| Have you ever
terminated your parental rights to a biological or
adopted child? |
Yes
If 'Yes' Please explain |
No |
|
ADOPTION POLICY REQUIRES YOU TO INCLUDE THE
non-refundable APPLICATION and
DISCLAIMER FEE OF
$300.00
ALONG WITH YOUR APPLICATION/DISCLAIMER/RELEASE OF
INFORMATION/PROFILE AND PHOTOS
You May Pay Using Cash, Check (See Address
below)
www.PAYPAL.COM to
account
Embryosalive@yahoo.com ( add 10.00 to include
Paypal pick up charges)
|
|
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You may sign and mail or print scan and e-mail this document TO
COMPLETE THE APPLICATION AND BEGIN THE PROCESS RIGHT
AWAY.
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| Signature : |
|
Date: |
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| Signature : |
|
Date: |
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